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Johnson KG, Ford C, Clark AG, Greiner MA, Lusk JB, Perry C, O'Brien R, O'Brien EC. Neuropsychiatric Comorbidities and Psychotropic Medication Use in Medicare Beneficiaries With Dementia by Sex and Race. J Geriatr Psychiatry Neurol 2024:8919887241254470. [PMID: 38769750 DOI: 10.1177/08919887241254470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Neuropsychiatric symptoms affect the majority of dementia patients. Past studies report high rates of potentially inappropriate prescribing of psychotropic medications in this population. We investigate differences in neuropsychiatric diagnoses and psychotropic medication prescribing in a local US cohort by sex and race. METHODS We utilize Medicare claims and prescription fill records in a cohort of 100% Medicare North and South Carolina beneficiaries ages 50 and above for the year 2017 with a dementia diagnosis. We identify dementia and quantify diagnosis of anxiety, depression and psychosis using validated coding algorithms. We search Medicare claims for antianxiety, antidepressant and antipsychotic medications to determine prescriptions filled. RESULTS Anxiety and depression were diagnosed at higher rates in White patients; psychosis at higher rates in Black patients. (P < .001) Females were diagnosed with anxiety, depression and psychosis at higher rates than males (P < .001) and filled more antianxiety and antidepressant medications than males. (P < .001) Black and Other race patients filled more antipsychotic medications for anxiety, depression and psychosis than White patients. (P < .001) Antidepressants were prescribed at higher rates than antianxiety or antipsychotic medications across all patients and diagnoses. Of patients with no neuropsychiatric diagnosis, 11.4% were prescribed an antianxiety medication, 22.8% prescribed an antidepressant and 7.6% prescribed an antipsychotic. CONCLUSIONS The high fill rate of antianxiety (benzodiazepine) medications in dementia patients, especially females is a concern. Patients are prescribed psychotropic medications at high rates. This practice may represent potentially inappropriate prescribing. Patient/caregiver education with innovative community outreach and care delivery models may help decrease medication use.
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Affiliation(s)
- Kim G Johnson
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Duke University, Durham, NC, USA
- Department of Neurology, Duke University, Durham, NC, USA
| | - Cassie Ford
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Amy G Clark
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Jay B Lusk
- School of Medicine, Duke University, Durham, NC, USA
- Fuqua School of Business, Duke University, Durham, NC, USA
| | - Cody Perry
- Trinity College of Arts and Sciences, Duke University, Durham, NC, USA
| | | | - Emily C O'Brien
- Department of Neurology, Duke University, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
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Riffin C, Mei L, Brody L, Herr K, Pillemer KA, Reid MC. Program of All-Inclusive Care for the Elderly: an untapped setting for research to advance pain care in older persons. FRONTIERS IN PAIN RESEARCH 2024; 5:1347473. [PMID: 38712020 PMCID: PMC11070459 DOI: 10.3389/fpain.2024.1347473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 04/10/2024] [Indexed: 05/08/2024] Open
Abstract
The Program of All-Inclusive Care for the Elderly (PACE) is a community-based care model in the United States that provides comprehensive health and social services to frail, nursing home-eligible adults aged 55 years and older. PACE organizations aim to support adequate pain control in their participants, yet few evidence-based pain interventions have been adopted or integrated into this setting. This article provides a roadmap for researchers who are interested in collaborating with PACE organizations to embed and evaluate evidence-based pain tools and interventions. We situate our discussion within the Consolidated Framework for Implementation Research (CFIR), a meta-theoretical framework that considers multi-level influences to implementation and evaluation of evidence-based programs. Within each CFIR domain, we identify key factors informed by our own work that merit consideration by research teams and PACE collaborators. Inner setting components pertain to the organizational culture of each PACE organization, the type and quality of electronic health record data, and availability of staff to assist with data abstraction. Outer setting components include external policies and regulations by the National PACE Association and audits conducted by the Centers for Medicare and Medicaid Services, which have implications for research participant recruitment and enrollment. Individual-level characteristics of PACE organization leaders include their receptivity toward new innovations and perceived ability to implement them. Forming and sustaining research-PACE partnerships to deliver evidence-based pain interventions pain will require attention to multi-level factors that may influence future uptake and provides a way to improve the health and well-being of patients served by these programs.
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Affiliation(s)
- Catherine Riffin
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Lauren Mei
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Lilla Brody
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Keela Herr
- College of Nursing, University of Iowa, Iowa City, IA, United States
| | - Karl A. Pillemer
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- College of Human Ecology, Cornell University, Ithaca, NY, United States
| | - M. Carrington Reid
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States
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Alageel NA, Hughes CM, Alwhaibi M, Alkeridy W, Barry HE. Potentially inappropriate prescribing for people with dementia in ambulatory care: a cross-sectional observational study. BMC Geriatr 2024; 24:328. [PMID: 38600444 PMCID: PMC11008018 DOI: 10.1186/s12877-024-04949-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 04/04/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Studies have shown that potentially inappropriate prescribing (PIP) is highly prevalent among people with dementia (PwD) and linked to negative outcomes, such as hospitalisation and mortality. However, there are limited data on prescribing appropriateness for PwD in Saudi Arabia. Therefore, we aimed to estimate the prevalence of PIP and investigate associations between PIP and other patient characteristics among PwD in an ambulatory care setting. METHODS A cross-sectional, retrospective analysis was conducted at a tertiary hospital in Saudi Arabia. Patients who were ≥ 65 years old, had dementia, and visited ambulatory care clinics between 01/01/2019 and 31/12/2021 were included. Prescribing appropriateness was evaluated by applying the Screening Tool of Older Persons Potentially Inappropriate Prescriptions (STOPP) criteria. Descriptive analyses were used to describe the study population. Prevalence of PIP and the prevalence per each STOPP criterion were calculated as a percentage of all eligible patients. Logistic regression analysis was used to investigate associations between PIP, polypharmacy, age and sex; odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Analyses were conducted using SPSS v27. RESULTS A total of 287 PwD were identified; 56.0% (n = 161) were female. The mean number of medications prescribed was 9.0 [standard deviation (SD) ± 4.2]. The prevalence of PIP was 61.0% (n = 175). Common instances of PIP were drugs prescribed beyond the recommended duration (n = 90, 31.4%), drugs prescribed without an evidence-based clinical indication (n = 78, 27.2%), proton pump inhibitors (PPIs) for > 8 weeks (n = 75, 26.0%), and acetylcholinesterase inhibitors with concurrent drugs that reduce heart rate (n = 60, 21.0%). Polypharmacy was observed in 82.6% (n = 237) of patients and was strongly associated with PIP (adjusted OR 24.1, 95% CI 9.0-64.5). CONCLUSIONS Findings have revealed a high prevalence of PIP among PwD in Saudi Arabia that is strongly associated with polypharmacy. Future research should aim to explore key stakeholders' experiences and perspectives of medicines management to optimise medication use for this vulnerable patient population.
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Affiliation(s)
- Nahla A Alageel
- Primary Care Research Group, School of Pharmacy, Medical Biology Centre, Queen's University Belfast, 97 Lisburn Road, BT9 7BL, Belfast, UK
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Carmel M Hughes
- Primary Care Research Group, School of Pharmacy, Medical Biology Centre, Queen's University Belfast, 97 Lisburn Road, BT9 7BL, Belfast, UK
| | - Monira Alwhaibi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Walid Alkeridy
- Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Department of Medicine, Geriatric Division, University of British Columbia, Vancouver, Canada
- General Administration of Home Health Care, Therapeutic Affairs Deputyship, Riyadh, Saudi Arabia
| | - Heather E Barry
- Primary Care Research Group, School of Pharmacy, Medical Biology Centre, Queen's University Belfast, 97 Lisburn Road, BT9 7BL, Belfast, UK.
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Zhang Y, Luo H, Lum TY, Knapp M, Vetrano DL, Chui CC, Wang P, Wong GH. Association of Comorbidity With Healthcare Utilization in People Living With Dementia, 2010-2019: A Population-Based Cohort Study. DEMENTIA 2024; 23:422-437. [PMID: 37211819 DOI: 10.1177/14713012231177593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Evidence on the healthcare utilization associated with comorbidity in people with dementia is lacking in Chinese societies. This study aimed to quantify healthcare utilization associated with comorbidity that is common in people living with dementia. We conducted a cohort study using population-based data from Hong Kong public hospitals. Individuals aged 35+ with a dementia diagnosis between 2010 and 2019 were included. Among 88,151 participants, people with at least two comorbidities accounted for 81.2%. Estimates from negative binomial regressions showed that compared to those with one or no comorbid condition other than dementia, adjusted rate ratios of hospitalizations among individuals with six or seven and eight or more conditions were 1.97 [98.75% CI, 1.89-2.05] and 2.74 [2.63-2.86], respectively; adjusted rate ratios of Accident and Emergency department visits among individuals with six or seven and eight or more conditions were 1.53 [1.44-1.63] and 1.92 [1.80-2.05], respectively. Comorbid chronic kidney diseases were associated with the highest adjusted rate ratios of hospitalizations (1.81 [1.74-1.89]), whereas comorbid chronic ulcer of the skin was associated with the highest adjusted rate ratios of Accident and Emergency department visits (1.73 [1.61-1.85]). Healthcare utilization for individuals with dementia differed substantially by both the number of comorbid chronic conditions and the presence of some specific comorbid conditions. These findings further highlight the importance of taking account of multiple long-term conditions in tailoring the care approach and developing healthcare plans for people with dementia.
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Affiliation(s)
- Yingyang Zhang
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, China
| | - Hao Luo
- Department of Social Work and Social Administration; Sau Po Centre on Ageing, The University of Hong Kong, Hong Kong, China
| | - Terry Ys Lum
- Department of Social Work and Social Administration; Sau Po Centre on Ageing, The University of Hong Kong, Hong Kong, China
| | - Martin Knapp
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Davide L Vetrano
- Aging Research Center, NVS Department, Karolinska Institutet, Stockholm University, Stockholm, Sweden; Stockholm Gerontology Research Center, Stockholm, Sweden
| | - Celine Cs Chui
- School of Nursing, The University of Hong Kong, Hong Kong, China; School of Public Health, The University of Hong Kong, Hong Kong, China; Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Hong Kong, China
| | - Pengcheng Wang
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, China
| | - Gloria Hy Wong
- Department of Social Work and Social Administration; Sau Po Centre on Ageing, The University of Hong Kong, Hong Kong, China
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Watson J, Green MA, Giebel C, Akpan A. Identifying longitudinal healthcare pathways and subsequent mortality for people living with dementia in England: an observational group-based trajectory analysis. BMC Geriatr 2024; 24:150. [PMID: 38350866 PMCID: PMC10865521 DOI: 10.1186/s12877-024-04744-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 01/24/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND The number of people living with dementia (PLWD) continues to increase, particularly those with severe symptomatology. Severe symptoms and greater ill-health result in more acute care need. Early healthcare interventions can prove beneficial. Healthcare use has not been analysed as a holistic set of interlinked events. This study explores different healthcare pathways among PLWD, social or spatial inequalities in healthcare pathways and subsequent mortality risk. METHODS Group-based trajectory models (GBTM) were applied to electronic healthcare records. We generated clusters of PLWD with similar five-year, post-diagnosis trajectories in rates of primary and secondary healthcare use. Potential social and spatial variations in healthcare use clusters were examined. Cox Proportional Hazards used to explore variation in subsequent mortality risk between healthcare use clusters. RESULTS Four healthcare use clusters were identified in both early- (n = 3732) and late-onset (n = 6224) dementia populations. Healthcare use variations were noted; consistent or diminishing healthcare use was associated with lower subsequent mortality risk. Increasing healthcare use was associated with increased mortality risk. Descriptive analyses indicated social and spatial variation in healthcare use cluster membership. CONCLUSION Healthcare pathways can help indicate changing need and variation in need, with differential patterns in initial healthcare use post-diagnosis, producing similar subsequent mortality risk. Care in dementia needs to be more accessible and appropriate, with care catered to specific and changing needs. Better continuity of care and greater awareness of dementia in primary can enhance prospects for PLWD. Research needs to further illuminate holistic care need for PLWD, including health and social care use, inequalities in care, health and outcomes.
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Affiliation(s)
- James Watson
- Department of Primary Care and Mental Health, The University of Liverpool, 1st Floor, Waterhouse Building B, Liverpool, L69 3GF, UK.
| | - Mark A Green
- School of Environmental Sciences, The University of Liverpool, Liverpool, UK
| | - Clarissa Giebel
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
- Applied Research Collaboration North West Coast, Liverpool, UK
| | - Asangaedem Akpan
- Department of Medicine for Older People and Stroke, Liverpool University Hospitals NHS FT, Liverpool, UK
- Healthy Ageing Group, University of Cumbria, Carlisle, UK
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Clinical Research Network, North West Coast, Liverpool, UK
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Singh S, Cocoros NM, Li X, Mazor KM, Antonelli MT, Parlett L, Paullin M, Harkins TP, Zhou Y, Rochon PA, Platt R, Dashevsky I, Massino C, Saphirak C, Crawford SL, Gurwitz JH. Developing a PRogram to Educate and Sensitize Caregivers to Reduce the Inappropriate Prescription Burden in the Elderly with Alzheimer's Disease (D-PRESCRIBE-AD): Trial protocol and rationale of an open-label pragmatic, prospective randomized controlled trial. PLoS One 2024; 19:e0297562. [PMID: 38346025 PMCID: PMC10861034 DOI: 10.1371/journal.pone.0297562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 11/02/2023] [Indexed: 02/15/2024] Open
Abstract
CONTEXT Potentially inappropriate prescribing of medications in older adults, particular those with dementia, can lead to adverse drug events including falls and fractures, worsening cognitive impairment, emergency department visits, and hospitalizations. Educational mailings from health plans to patients and their providers to encourage deprescribing conversations may represent an effective, low-cost, "light touch", approach to reducing the burden of potentially inappropriate prescription use in older adults with dementia. OBJECTIVES The objective of the Developing a PRogram to Educate and Sensitize Caregivers to Reduce the Inappropriate Prescription Burden in Elderly with Alzheimer's Disease (D-PRESCRIBE-AD) trial is to evaluate the effect of a health plan based multi-faceted educational outreach intervention to community dwelling patients with dementia who are currently prescribed sedative/hypnotics, antipsychotics, or strong anticholinergics. METHODS The D-PRESCRIBE-AD is an open-label pragmatic, prospective randomized controlled trial (RCT) comparing three arms: 1) educational mailing to both the health plan patient and their prescribing physician (patient plus physician arm, n = 4814); 2) educational mailing to prescribing physician only (physician only arm, n = 4814); and 3) usual care (n = 4814) among patients with dementia enrolled in two large United States based health plans. The primary outcome is the absence of any dispensing of the targeted potentially inappropriate prescription during the 6-month study observation period after a 3-month black out period following the mailing. Secondary outcomes include dose-reduction, polypharmacy, healthcare utilization, mortality and therapeutic switching within targeted drug classes. CONCLUSION This large pragmatic RCT will contribute to the evidence base on promoting deprescribing of potentially inappropriate medications among older adults with dementia. If successful, such light touch, inexpensive and highly scalable interventions have the potential to reduce the burden of potentially inappropriate prescribing for patients with dementia. ClinicalTrials.gov Identifier: NCT05147428.
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Affiliation(s)
- Sonal Singh
- Department of Family Medicine and Community Health, Division of Health Systems Science, Umass Chan Medical School, Worcester, Massachusetts, United States of America
| | - Noelle M. Cocoros
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Xiaojuan Li
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Kathleen M. Mazor
- Division of Health Systems Science, UMass Chan Medical School, Worcester, Massachusetts, United States of America
| | - Mary T. Antonelli
- Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, Worcester, Massachusetts, United States of America
| | - Lauren Parlett
- Carelon Research, Wilmington, Delaware, United States of America
| | - Mark Paullin
- Carelon Research, Wilmington, Delaware, United States of America
| | - Thomas P. Harkins
- Humana Healthcare Research, Inc., (Humana), Louisville, Kentucky, United States of America
| | - Yunping Zhou
- Humana Healthcare Research, Inc., (Humana), Louisville, Kentucky, United States of America
| | - Paula A. Rochon
- Women’s Age Lab and Women’s College Research Institute, Women’s College Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Richard Platt
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Inna Dashevsky
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Carly Massino
- Division of Health Systems Science, UMass Chan Medical School, Worcester, Massachusetts, United States of America
| | - Cassandra Saphirak
- Division of Health Systems Science, UMass Chan Medical School, Worcester, Massachusetts, United States of America
| | - Sybil L. Crawford
- Division of Health System Science, UMass Chan Medical School, Tan Chingfen Graduate School of Nursing, Worcester, Massachusetts, United States of America
| | - Jerry H. Gurwitz
- Division of Geriatric Medicine and Division of Health Systems Science, UMass Chan Medical School, Worcester, Massachusetts, United States of America
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Chenoweth L. Supporting shared decision-making in medicines use with people living with dementia and their carers. Nurs Older People 2024:e1458. [PMID: 38263893 DOI: 10.7748/nop.2024.e1458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 01/25/2024]
Abstract
Polypharmacy and inappropriate prescribing of psychotropic medicines are common among people living with dementia and pose considerable health risks. One way of addressing these issues is by involving the person and their carer in shared decision-making. This article discusses some of the issues related to polypharmacy and inappropriate prescribing in people living with dementia and examines the concept of shared decision-making in this context. The author details some practical aids that nurses and other healthcare professionals can use to engage people living with dementia and their carers in shared decision-making about medicines use.
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Affiliation(s)
- Lynn Chenoweth
- School of Clinical Medicine, Centre for Healthy Brain Ageing, University of New South Wales, Kennington, NSW, Australia
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Douglas NF, Browning S, Claypool K. Preliminary Evidence for Dementia Collaborative Coaching. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2023; 32:2146-2157. [PMID: 37437528 PMCID: PMC10567118 DOI: 10.1044/2023_ajslp-22-00367] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/11/2023] [Accepted: 05/08/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE The primary purpose of this study was to obtain preliminary evidence for a communication coaching intervention, Dementia Collaborative Coaching. The secondary aim of this study was to assess the acceptability, appropriateness, and feasibility of the intervention according to routine care providers. METHOD In a pre-/posttest design, speech-language pathologists (SLPs) delivered Dementia Collaborative Coaching to certified nursing assistants (CNAs) and people living with dementia (PLWD) in six different skilled nursing facilities over a period of 6 weeks. A self-perceived knowledge and efficacy measure regarding the use of external memory aids to support communication in PLWD was administered to CNA and SLP participants. The Cohen-Mansfield Agitation Inventory was administered to PLWD participants. The Acceptability of Intervention Measure, Intervention Appropriateness Measure, and Feasibility of Intervention Measure were administered post-intervention. RESULTS For CNAs, self-perceived knowledge and efficacy increased from pre-intervention (M = 3.73, SD = 0.69) to post-intervention (M = 4.07, SD = 0.44), t(11) = -1.97, one-sided p = .037. There was a significant improvement (e.g., reduction) in scores on the Cohen-Mansfield Agitation Inventory for PLWD (n = 10) from pre-intervention (M = 73.10, SD = 29.98) to post-intervention (M = 58.6, SD = 18.82), t(9) = 2.83, p = .01. CNA participants (n = 12) rated the intervention as acceptable (M = 4.48, SD = 0.48), appropriate (M = 4.33, SD = 0.61), and feasible (M = 4.19, SD = 0.48). SLPs rated the intervention as slightly more acceptable, appropriate, and feasible than CNAs with scores of M = 4.54, SD = 0.51; M = 4.54, SD = 0.51; and M = 4.46, SD = 0.51, respectively. CONCLUSIONS Dementia Collaborative Coaching showed preliminary positive outcomes for CNAs and PLWD. The intervention was acceptable, appropriate, and feasible for routine providers and warrants further study.
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Affiliation(s)
- Natalie F. Douglas
- Department of Communication Sciences and Disorders, Central Michigan University, Mount Pleasant
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Kosteniuk JG, Morgan DG, Osman BA, Islam N, O’Connell ME, Kirk A, Quail JM, Osman M. Utilization of Health Services Before and After Diagnosis in a Specialist Rural and Remote Memory Clinic. Can Geriatr J 2023; 26:350-363. [PMID: 37662065 PMCID: PMC10444530 DOI: 10.5770/cgj.26.653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023] Open
Abstract
Background Limited research exists on the use of specific health services over an extended time among rural persons with dementia. The study objective was to examine health service use over a 10-year period, five years before until five years after diagnosis in the specialist Rural and Remote Memory Clinic (RRMC). Methods Clinical and administrative health data of RRMC patients were linked. Annual health service utilization of the cohort (N = 436) was analyzed for 416 patients pre-index (57.5% female, mean age 71.2 years) and 419 post-index (56.3% female, mean age 70.8 years). Approximately 40% of memory clinic diagnoses were Alzheimer's disease (AD), 20% non-AD dementia, and 40% mild or subjective cognitive impairment or other condition. Post-index, 188 patients (44.9%) moved to permanent long-term care and were retained in the sample; 121 patients died (28.9%) and were removed yearly. Results Over the ten-year study period, a significant increase occurred in the average number of FP visits, all-type drug prescriptions, and dementia-specific drug prescriptions (all p <.001). The highest proportion of patients hospitalized was observed one year pre-index, the highest average number of specialist visits was observed one year post-index, and both demonstrated a significant decreasing trend in the five-year post-index period (p = .037). Conclusions A pattern of increasing FP visits and drug prescriptions over an extended period before and after diagnosis in a specialist rural and remote memory clinic highlights a need to support FPs in post-diagnostic management. Further research of longitudinal patterns in health service utilization is merited.
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Affiliation(s)
- Julie G. Kosteniuk
- Canadian Centre for Health & Safety in Agriculture, University of Saskatchewan, Saskatoon
| | - Debra G. Morgan
- Canadian Centre for Health & Safety in Agriculture, University of Saskatchewan, Saskatoon
| | - Beliz Acan Osman
- Saskatchewan Health Quality Council, Atrium Building, Innovation Place, Saskatoon
| | - Naorin Islam
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon
| | | | - Andrew Kirk
- Department of Medicine, University of Saskatchewan, Saskatoon
| | - Jacqueline M. Quail
- Saskatchewan Health Quality Council, Atrium Building, Innovation Place, Saskatoon
| | - Meric Osman
- Saskatchewan Medical Association, Saskatoon, SK, Canada
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Zhao M, Chen Z, Xu T, Fan P, Tian F. Global prevalence of polypharmacy and potentially inappropriate medication in older patients with dementia: a systematic review and meta-analysis. Front Pharmacol 2023; 14:1221069. [PMID: 37693899 PMCID: PMC10483131 DOI: 10.3389/fphar.2023.1221069] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/03/2023] [Indexed: 09/12/2023] Open
Abstract
Background: Older patients with dementia always need multiple drugs due to comorbidities and cognitive impairment, further complicating drug treatment and increasing the risk of potentially inappropriate medication. The objective of our study is to estimate the global prevalence of polypharmacy and potentially inappropriate medication (PIM) and explore the factors of PIM for older patients with dementia. Methods: We searched PubMed, Embase (Ovid), and Web of Science databases to identify eligible studies from inception to 16 June 2023. We conducted a meta-analysis for observational studies reporting the prevalence of potentially inappropriate medication and polypharmacy in older patients with dementia using a random-effect model. The factors associated with PIM were meta-analyzed. Results: Overall, 62 eligible studies were included, of which 53 studies reported the prevalence of PIM and 28 studies reported the prevalence of polypharmacy. The pooled estimate of PIM and polypharmacy was 43% (95% CI 38-48) and 62% (95% CI 52-71), respectively. Sixteen studies referred to factors associated with PIM use, and 15 factors were further pooled. Polypharmacy (2.83, 95% CI 1.80-4.44), diabetes (1.31, 95% CI 1.04-1.65), heart failure (1.17, 95% CI 1.00-1.37), depression (1.45, 95% CI 1.14-1.88), history of cancer (1.20, 95% CI 1.09-1.32), hypertension (1.46, 95% CI 1.05-2.03), ischemic heart disease (1.55, 95% CI 0.77-3.12), any cardiovascular disease (1.11, 95% CI 1.06-1.17), vascular dementia (1.09, 95% CI 1.03-1.16), chronic obstructive pulmonary disease (1.39, 95% CI 1.13-1.72), and psychosis (1.91, 95% CI 1.04-3.53) are positively associated with PIM use. Conclusion: PIM and polypharmacy were highly prevalent in older patients with dementia. Among different regions, the pooled estimate of PIM use and polypharmacy varied widely. Increasing PIM in older patients with dementia was closely associated with polypharmacy. For other comorbidities such as heart failure and diabetes, prescribing should be cautioned.
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Affiliation(s)
| | | | | | - Ping Fan
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fangyuan Tian
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Tsunawaki S, Abe M, DeJonckheere M, Cigolle CT, Philips KK, Rubinstein EB, Matsuda M, Fetters MD, Inoue M. Primary care physicians' perspectives and challenges on managing multimorbidity for patients with dementia: a Japan-Michigan qualitative comparative study. BMC PRIMARY CARE 2023; 24:132. [PMID: 37370035 DOI: 10.1186/s12875-023-02088-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/22/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Multimorbidity management can be extremely challenging in patients with dementia. This study aimed to elucidate the approaches of primary care physicians in Japan and the United States (US) in managing multimorbidity for patients with dementia and discuss the challenges involved. METHODS This qualitative study was conducted through one-on-one semi-structured interviews among primary care physicians, 24 each from Japan and Michigan, US. Thematic and content analyses were performed to explore similarities and differences among each country's data. RESULTS Primary care physicians in Japan and Michigan applied a relaxed adherence to the guidelines for patients' chronic conditions. Common challenges were the suboptimal consultation time, the insufficient number or ability of care-coordinating professionals, patients' conditions such as difficulties with self-management, living alone, behavioral issues, and refusal of care support. Unique challenges in Japan were free-access medical systems and not being sure about the patients' will in end-of-life care. In Michigan, physicians faced challenges in distance and lack of transportation between clinics and patients' homes and in cases where patients lacked the financial ability to acquire good care. CONCLUSIONS To improve the quality of care for patients with multimorbidity and dementia, physicians would benefit from optimal time and compensation allocated for this patient group, guidelines for chronic conditions to include information regarding changing priority for older adults with dementia, and the close collaboration of medical and social care and community resources with support of skilled care-coordinating professionals.
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Affiliation(s)
- Shinji Tsunawaki
- Omaezaki Family Medicine Center, Omaezaki, Shizuoka, Japan
- Shizuoka Family Medicine Program, Shizuoka, Hamamatsu, Japan
| | - Michiko Abe
- Department of Family and Community Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | | | - Christine T Cigolle
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Education and Clinical Center (GRECC), VA Ann Arbor Healthcare System (VAAAHS) Geriatric Research, Ann Arbor, MI, USA
| | - Kristin K Philips
- Education and Clinical Center (GRECC), VA Ann Arbor Healthcare System (VAAAHS) Geriatric Research, Ann Arbor, MI, USA
| | - Ellen B Rubinstein
- Department of Sociology and Anthropology, North Dakota State University, Fargo, ND, USA
| | - Masakazu Matsuda
- Shizuoka Family Medicine Program, Shizuoka, Hamamatsu, Japan
- Kikugawa Family Medicine Center, Kikugawa, Shizuoka, Japan
| | - Michael D Fetters
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
- The School of Health Humanities, Peking University Health Science Center, Beijing, China
| | - Machiko Inoue
- Shizuoka Family Medicine Program, Shizuoka, Hamamatsu, Japan.
- Department of Family and Community Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan.
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12
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Liu AK, Possin KL, Cook KM, Lynch S, Dulaney S, Merrilees JJ, Braley T, Kiekhofer RE, Bonasera SJ, Allen IE, Chiong W, Clark AM, Feuer J, Ewalt J, Guterman EL, Gearhart R, Miller BL, Lee KP. Effect of collaborative dementia care on potentially inappropriate medication use: Outcomes from the Care Ecosystem randomized clinical trial. Alzheimers Dement 2023; 19:1865-1875. [PMID: 36331050 PMCID: PMC10156873 DOI: 10.1002/alz.12808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/11/2022] [Accepted: 08/29/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Potentially inappropriate medications (PIMs) cause adverse events and death. We evaluate the Care Ecosystem (CE) collaborative dementia care program on medication use among community-dwelling persons living with dementia (PLWD). METHODS Secondary analysis of a randomized clinical trial (RCT) comparing CE to usual care (UC) on changes in PIMs, over 12 months between March 2015 and May 2020. Secondary outcomes included change in number of medications, clinically relevant PIMs, and anti-dementia medications. RESULTS Of 804 PLWD, N = 490 had complete medication data. The CE resulted in significantly fewer PIMs compared to UC (-0.35; 95% CI, -0.49 to -0.20; P < 0.0001). Number needed to prevent an increase in 1 PIM was 3. Total medications, PIMs for dementia or cognitive impairment, CNS-active PIMs, anticholinergics, benzodiazepines, and opioids were also fewer. Anti-dementia medication regimens were modified more frequently. CONCLUSION The CE medication review intervention embedded in collaborative dementia care optimized medication use among PLWD. HIGHLIGHTS Compared to usual care (UC), the Care Ecosystem (CE) medication review intervention prevented increases in potentially inappropriate medications (PIMs). Use of anticholinergics, benzodiazepines, and opioids were significantly reduced, with a trend for antipsychotics. Anti-dementia medications were adjusted more frequently. The CE medication review intervention embedded in collaborative dementia care optimized medication use.
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Affiliation(s)
- Amy K. Liu
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California, USA
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Katherine L. Possin
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
- Global Brain Health Institute, University of California, San Francisco, San Francisco, California, USA
| | - Kristen M. Cook
- Department of Pharmacy Practice and Science, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Shalini Lynch
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California, USA
| | - Sarah Dulaney
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer J. Merrilees
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Tamara Braley
- Division of Geriatrics, Gerontology, and Palliative Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Rachel E. Kiekhofer
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Stephen J. Bonasera
- Division of Geriatrics, Gerontology, and Palliative Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Isabel E. Allen
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Winston Chiong
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Amy M. Clark
- Division of Geriatrics, Gerontology, and Palliative Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Julie Feuer
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Joan Ewalt
- Division of Geriatrics, Gerontology, and Palliative Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Elan L. Guterman
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
| | - Rosalie Gearhart
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Bruce L. Miller
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Kirby P. Lee
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California, USA
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Parchman ML, Perloff J, Ritter G. Can clinician champions reduce potentially inappropriate medications in people living with dementia? Study protocol for a cluster randomized trial. Implement Sci 2022; 17:63. [PMID: 36163181 PMCID: PMC9513870 DOI: 10.1186/s13012-022-01237-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/14/2022] [Indexed: 11/10/2022] Open
Abstract
Background For people living with dementia (PLWD) the overuse of potentially inappropriate medications (PIMs) remains a persistent problem. De-prescribing trials in the elderly have mixed results. Clinician champions may be uniquely suited to lead efforts to address this challenge. Here we describe the study protocol for a 24-month embedded pragmatic cluster-randomized clinical trial within two accountable care organizations (ACOs) of such a clinician champion intervention. The specific aims are to (1) assess the effectiveness of a clinician champion on de-implementing PIMs in PLWD, (2) determine if the intervention is associated with a reduction in emergency department (ED) visits and hospitalizations attributed to a fall, and (3) examine five implementation outcomes: appropriateness, feasibility, fidelity, penetration, and equity. Methods/design Two ACOs agreed to participate: United States Medical Management (USMM) and Oschner Health System. The unit of randomization will be the primary care clinic. A clinician champion will be recruited from each of the intervention clinics to participate in a 6-month training program and then work with clinicians and staff in their clinic for 12 months to reduce the use of PIMs in their PLWD population. For aims 1 and 2, Medicare claims data will be used to assess outcomes. The outcome for aim #1 will be medication possession rates per quarter, for the three therapeutic classes of PIMs among patients with dementia in intervention clinics versus control clinics. For aim #2, we will assess the incidence of falls using a previously validated algorithm. For both aims 1 and 2, we will construct hierarchical models with time period observations nested within patient using generalized estimating equations (GEE) with robust standard errors. The key variable of interest will be the treatment indicator assigned based on practice. For aim #3, we will conduct qualitative thematic analysis of documentation by the clinician champions in their project workbooks to evaluate the five implementation outcomes. Discussion This embedded pragmatic trial will add to our existing knowledge regarding the effectiveness of a clinician champion strategy to de-prescribe potentially inappropriate medication among patients with dementia as well as its appropriateness, feasibility, fidelity, penetration, and equity. Trial registration Clinicaltrials.govNCT05359679, Registered May 4, 2022
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Affiliation(s)
- Michael L Parchman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA.
| | - Jennifer Perloff
- Brandeis University, Waltham, MA, USA.,Institute for Accountable Care, Washington, DC, USA
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Yoon K, Kim JT, Kwack WG, Kim D, Lee KT, Yang S, Lee S, Choi YJ, Chung EK. Potentially Inappropriate Medication Use in Patients with Dementia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11426. [PMID: 36141699 PMCID: PMC9517486 DOI: 10.3390/ijerph191811426] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 06/16/2023]
Abstract
The objective of this study was to characterize the epidemiology of using potentially inappropriate medications associated with dementia exacerbation (DPIMs) in elderly outpatients with dementia. Electronic medical records were retrospectively reviewed for geriatric patients with dementia who were prescribed at least one medication in 2016 at a tertiary, university-affiliated hospital. The 2015 Beers criteria were used to define DPIMs. Logistic regression was performed to identify factors associated with prescribing DPIMs in patients with dementia. Among 2100 patients included in our study, 987 (47.0%) patients were prescribed at least one DPIM. Benzodiazepines were the most frequently prescribed DPIM followed by anticholinergics, histamine H2-receptor blockers, and zolpidem. The risk of prescribing DPIMs was significantly increased in female patients (odds ratio (OR) 1.355) with polypharmacy (OR 5.146) and multiple comorbidities (OR 1.129) (p < 0.05 for all). Coexistence of Parkinson's disease (OR 1.799), mood disorder (OR 1.373), or schizophrenia (OR 4.116) in patients with dementia further increased the likelihood of receiving DPIMs. In conclusion, DPIMs were commonly used in elderly patients with dementia in Korea with benzodiazepines most frequently prescribed followed by anticholinergics. Female patients using polypharmacy with multiple comorbidities should be closely monitored to minimize unnecessary DPIM use and, ultimately, DPIM-related harms.
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Affiliation(s)
- Kyungwon Yoon
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, Seoul 02447, Korea
- Department of Pharmacy, Kyung Hee University Hospital, Seoul 02447, Korea
| | - Jung-Tae Kim
- Department of Pharmacy, Kyung Hee University Hospital at Gangdong, Seoul 05278, Korea
| | - Won-Gun Kwack
- Division of Pulmonary, Allergy and Critical Care Medicine, Kyung Hee University Hospital, Seoul 02447, Korea
| | - Donghyun Kim
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, Seoul 02447, Korea
| | - Kyung-Tae Lee
- Department of Biomedical and Pharmaceutical Sciences, Graduate School, Kyung Hee University, Seoul 02447, Korea
- Department of Pharmaceutical Biochemistry, College of Pharmacy, Kyung Hee University, Seoul 02447, Korea
| | - Seungwon Yang
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, Seoul 02447, Korea
- Department of Regulatory Science, College of Pharmacy, Graduate School, Kyung Hee University, Seoul 02447, Korea
| | - Sangmin Lee
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, Seoul 02447, Korea
- Department of Regulatory Science, College of Pharmacy, Graduate School, Kyung Hee University, Seoul 02447, Korea
| | - Yeo-Jin Choi
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, Seoul 02447, Korea
- Department of Regulatory Science, College of Pharmacy, Graduate School, Kyung Hee University, Seoul 02447, Korea
| | - Eun-Kyoung Chung
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, Seoul 02447, Korea
- Department of Pharmacy, Kyung Hee University Hospital at Gangdong, Seoul 05278, Korea
- Department of Regulatory Science, College of Pharmacy, Graduate School, Kyung Hee University, Seoul 02447, Korea
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15
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Rangfast I, Sönnerstam E, Gustafsson M. Prevalence of potentially inappropriate medications among old people with major neurocognitive disorder in 2012 and 2017. BMC Geriatr 2022; 22:544. [PMID: 35773643 PMCID: PMC9245287 DOI: 10.1186/s12877-022-03240-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/23/2022] [Indexed: 11/10/2022] Open
Abstract
Background The increased risk of adverse drug reactions due to age-related altered pharmacokinetics and pharmacodynamics is a challenge when prescribing medications to older people, and especially among older people with major neurocognitive disorder who are particularly sensitive to drug effects. The aim of this study was to investigate the use of potential inappropriate medications (PIMs) in 2012 and 2017 among old people with major neurocognitive disorder. A secondary aim was to investigate factors associated with PIM use. Methods This register-study was based on the Swedish registry for cognitive/dementia disorders and the Swedish prescribed drug register. Criteria from the National Board of Health and Welfare were used to identify PIMs between 1 July–31 December 2012 and 1 July-–31 December 2017 among people ≥ 65 years. Drug use was defined as one or more filled prescriptions during each timeframe. Results The total use of PIMs declined significantly between 2012 (28.7%) and 2017 (21.7%). All PIMs and PIM groups declined between these years, except for antipsychotic drugs, which increased from 11.6% to 12.3%. The results from the multiple regression model found that PIM use was associated with younger age (OR: 0.97 CI: 0.96–0.97), a lower Mini Mental State Examination score (OR: 0.99 CI: 0.99–1.00), the use of multi-dispensed drugs (OR: 2.05 CI: 1.93–2.18), and compared to Alzheimer’s disease, with the subtypes dementia with Lewy bodies and Parkinson’s disease dementia (OR: 1.57 CI: 1.40–1.75), frontotemporal dementia (OR: 1.29 CI: 1.08–1.54) and vascular dementia (OR: 1.10 CI: 1.03–1.16). Conclusions Overall, the use of PIMs decreased between the years 2012 and 2017. The increase of antipsychotic drugs and the association between PIM use and multi-dispensed drugs warrant concern. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03240-y.
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Affiliation(s)
- Iris Rangfast
- Department of Integrative Medical Biology, Umeå University, 901 87, Umeå, Sweden
| | - Eva Sönnerstam
- Department of Integrative Medical Biology, Umeå University, 901 87, Umeå, Sweden
| | - Maria Gustafsson
- Department of Integrative Medical Biology, Umeå University, 901 87, Umeå, Sweden.
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16
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Dementia-related continuing education for rural interprofessional primary health care in Saskatchewan, Canada: perceptions and needs of webinar participants. Prim Health Care Res Dev 2022; 23:e32. [PMID: 35604026 PMCID: PMC9247685 DOI: 10.1017/s1463423622000226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Dementia-related continuing education opportunities are important for rural primary health care (PHC) professionals given scarce specialized resources. This report explores the initial perceptions and continuing education needs of rural interprofessional memory clinic team members and other PHC professionals related to a short series of dementia-related education webinars. Three webinars on separate topics were delivered over an 8-month period in 2020 in Saskatchewan, Canada. The research design involved analysis of webinar comments and post-webinar survey data. Sixty-eight individuals participated in at least one webinar, and 46 surveys were completed. Rural memory clinic team members accounted for a minority of webinar participants and a majority of survey respondents. Initial perceptions were positive, with webinar topics and interactivity identified as the most effective aspects. Continuing education needs were mainly aligned with professional roles; however, some overlap of interests occurred. Future webinars will further explore learning needs within an interprofessional environment.
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Caçador C, Teixeira-Lemos E, Oliveira J, Pinheiro J, Teixeira-Lemos L, Ramos F. The Prevalence of Polypharmacy and Potentially Inappropriate Medications and Its Relationship with Cognitive Status in Portuguese Institutionalized Older Adults: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19052637. [PMID: 35270323 PMCID: PMC8910092 DOI: 10.3390/ijerph19052637] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/15/2022] [Accepted: 02/20/2022] [Indexed: 11/25/2022]
Abstract
The aim of this study was to evaluate the prevalence of polypharmacy and potentially inappropriate medications (PIMs) in a population of older adults living in nursing homes. Furthermore, we also intended to assess the possible association between polypharmacy, potentially inappropriate medications and cognitive impairment in institutionalized older adults. A cross-sectional study analyzed data from 193 nursing home residents in the district of Viseu, Portugal, between September 2018 and June 2019, with a mean age of 82.4 ± 6.2 years (ranging from 65 to 95 years old); 72.5% (n = 140) were female participants. Major polypharmacy was presented in 80.8% of the study population, who took 7.6 ± 3.3 drugs per day. Using the Beers Criteria, we found that 79.3% took PIMs. There was a positive association between polypharmacy and PIM (p < 0.001), showing that higher medicines intake increased the number of PIMs. Polypharmacy was not associated with the functionality of the older adults to perform activities of daily living, but was associated with cognitive impairment. The older adults with lower scores on the Mini Mental State Examination (MMSE) took more drugs (p = 0.039) and used more PIM (p < 0.001). Moreover, patients taking five or more prescription drugs per day (major polypharmacy) consuming any psychiatric, gastrointestinal or oral antidiabetic agents (regardless of whether they were considered potentially inappropriate or not) had higher odds of displaying cognitive impairment than those who did not (p < 0.05). Older adult residents of the studied nursing homes were potentially affected by polypharmacy and inappropriate polypharmacy. This observation reveals the need to adopt and implement strategies that make drug therapy more adequate and safer for older adults.
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Affiliation(s)
- Catarina Caçador
- Faculty of Pharmacy, University of Coimbra, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal;
| | - Edite Teixeira-Lemos
- ESAV, Polytechnic Institute of Viseu, 3500-606 Viseu, Portugal; (E.T.-L.); (J.O.)
- CERNAS-IPV Research Centre, Polytechnic Institute of Viseu, 3504-510 Viseu, Portugal
| | - Jorge Oliveira
- ESAV, Polytechnic Institute of Viseu, 3500-606 Viseu, Portugal; (E.T.-L.); (J.O.)
- CERNAS-IPV Research Centre, Polytechnic Institute of Viseu, 3504-510 Viseu, Portugal
| | - João Pinheiro
- Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal;
| | - Luís Teixeira-Lemos
- Nuclear Medicine Department, Centro Hospitalar e Universitário de Coimbra (CHUC), 3004-561 Coimbra, Portugal;
| | - Fernando Ramos
- Faculty of Pharmacy, University of Coimbra, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal;
- REQUIMTE/LAQV, R. D. Manuel II, Apartado, 55142 Oporto, Portugal
- Correspondence: or ; Tel.: +351-239-488492; Fax: +351-239-488503
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Continuity of GP care for patients with dementia: impact on prescribing and the health of patients. Br J Gen Pract 2022; 72:e91-e98. [PMID: 35074796 PMCID: PMC8803082 DOI: 10.3399/bjgp.2021.0413] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 11/03/2021] [Indexed: 12/31/2022] Open
Abstract
Background Higher continuity of GP care (CGPC), that is, consulting the same doctor consistently, can improve doctor–patient relationships and increase quality of care; however, its effects on patients with dementia are mostly unknown. Aim To estimate the associations between CGPC and potentially inappropriate prescribing (PIP), and with the incidence of adverse health outcomes (AHOs) in patients with dementia. Design and setting A retrospective cohort study with 1 year of follow-up anonymised medical records from 9324 patients with dementia, aged ≥65 years living in England in 2016. Method CGPC measures include the Usual Provider of Care (UPC), Bice–Boxerman Continuity of Care (BB), and Sequential Continuity (SECON) indices. Regression models estimated associations with PIPs and survival analysis with incidence of AHOs during the follow-up adjusted for age, sex, deprivation level, 14 comorbidities, and frailty. Results The highest quartile (HQ) of UPC (highest continuity) had 34.8% less risk of delirium (odds ratio [OR] 0.65, 95% confidence interval [CI] = 0.51 to 0.84), 57.9% less risk of incontinence (OR 0.42, 95% CI = 0.31 to 0.58), and 9.7% less risk of emergency admissions to hospital (OR 0.90, 95% CI = 0.82 to 0.99) compared with the lowest quartile. Polypharmacy and PIP were identified in 81.6% (n = 7612) and 75.4% (n = 7027) of patients, respectively. The HQ had fewer prescribed medications (HQ: mean 8.5, lowest quartile (LQ): mean 9.7, P<0.01) and had fewer PIPs (HQ: mean 2.1, LQ: mean 2.5, P<0.01), including fewer loop diuretics in patients with incontinence, drugs that can cause constipation, and benzodiazepines with high fall risk. The BB and SECON measures produced similar findings. Conclusion Higher CGPC for patients with dementia was associated with safer prescribing and lower rates of major adverse events. Increasing continuity of care for patients with dementia may help improve treatment and outcomes.
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Coffey A, Hartigan I, Timmons S, Buckley C, Lehane E, O'Loughlin C, O'Connell S, Cornally N. Implementation of evidence-based guidance for dementia palliative care using participatory action research: examining implementation through the Consolidated Framework for Implementation Research (CFIR). Implement Sci Commun 2021; 2:137. [PMID: 34895359 PMCID: PMC8665505 DOI: 10.1186/s43058-021-00241-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 11/17/2021] [Indexed: 11/24/2022] Open
Abstract
Background The importance of providing evidence-based palliative care for people with dementia is increasingly acknowledged as important for patient outcomes. In Ireland, evidence-based guidance has been developed in order to address key features of dementia palliative care, including the management of pain, medications and hydration and nutrition. The aim of this study was to identify and explore the factors affecting the implementation of evidence-based guidance on dementia palliative care. Methods The Consolidated Framework for Implementation (CFIR) guided a mixed-method pre-post study. One guidance document pertaining to the management of pain, medication or hydration and nutrition was implemented in three long-term care facilities. Participatory action research in the form of work-based learning groups was used to implement the guidance, drawing on a situational analysis (pre-implementation). Staff questionnaires and audits were conducted pre- and post-implementation while champion interviews were also conducted post-implementation. Results Features of the guidance, the inner setting components such as readiness to change, and the process of implementation were most frequently identified as impacting implementation. Components of the outer setting, such as external policy incentives and individual characteristics, featured less commonly. Data from qualitative interviews revealed that the guidance was perceived as advantageous or complimentary to previous care provided. Within the inner setting, leadership and support from other colleagues facilitated implementation. However, limited availability of other healthcare professionals to assist with carrying out guidance actions presented a barrier in some facilities. The external facilitators of the work-based learning groups (WBLGs) were perceived as experienced and encouraged active participation and reflection on practices. Despite the challenge of releasing staff to attend the WBLGs, quantitative data demonstrated reduced staff de-motivation amongst those who did attend was noted post-implementation (pre-Mdn = 19.50 versus post-Mdn = 22.00, U = 497.00, p = 0.07). Conclusions A situational analysis informed by the CFIR framework in conjunction with a participatory action research approach helped to advance the implementation of the guidance. The progress of implementation depended on the extent to which evidence-based care was previously being implemented at each site. Post-implementation analysis using CFIR identified challenges to address in future projects such as staff cover and timing of training to facilitate attendance for staff with different working hours. Facilitators included multidisciplinary engagement with the intervention and champions at each site to support the implementation process. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00241-7.
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Affiliation(s)
- Alice Coffey
- Health Implementation Science and Technology Cluster, Health Research Institute, University of Limerick, Limerick, Ireland. .,Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland.
| | - Irene Hartigan
- Catherine McAuley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
| | - Catherine Buckley
- Catherine McAuley School of Nursing and Midwifery, University College Cork, Cork, Ireland.,Northridge House Education and Research Centre, St Lukes Nursing Home, Cork, Ireland
| | - Elaine Lehane
- Catherine McAuley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | | | - Selena O'Connell
- Health Implementation Science and Technology Cluster, Health Research Institute, University of Limerick, Limerick, Ireland.,Catherine McAuley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Nicola Cornally
- Catherine McAuley School of Nursing and Midwifery, University College Cork, Cork, Ireland
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McConeghy KW, Curyto K, Jedele J, Intrator O, Mohr DC, Wiechers IR, Karel MJ. Impact of an interdisciplinary intervention for distress behaviors in dementia on psychotropic drug use in Veterans Health Administration Community Living Centers: STAR-VA impact on psychotropic drug utilization. Geriatr Nurs 2021; 42:1533-1540. [PMID: 34739929 DOI: 10.1016/j.gerinurse.2021.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/01/2021] [Accepted: 10/05/2021] [Indexed: 11/17/2022]
Abstract
STAR-VA is an interdisciplinary behavioral approach for managing distress behaviors in residents with dementia, implemented at Veterans Health Administration nursing homes. This study evaluated the impact of STAR-VA implementation on psychotropic drug use. The study design is a retrospective, quasi-experimental cohort analysis of residents enrolled as STAR-VA training cases compared with eligible residents at untrained sites to evaluate treatment effects on psychotropic medication use. We matched 229 STAR-VA cases with 1,163 comparisons. STAR-VA cases experienced an average reduction of 0.92 "as-needed" doses per month (95% confidence interval [CI] -1.82, -0.02) compared with controls. No significant effect on non-STAR-VA cases in trained facilities was detected. STAR-VA programs are an important option for reducing potentially inappropriate psychotropic use.
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Affiliation(s)
- Kevin W McConeghy
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, United States; Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, United States.
| | - Kim Curyto
- Department of Veterans Affairs, VA Western NY Healthcare System, Center for Integrated Healthcare, NY, United States
| | - Jenefer Jedele
- Serious Mental Illness Treatment Resource Evaluation Center, Department of Veterans Affairs, Office of Mental Health and Suicide Prevention, Ann Arbor, MI, United States
| | - Orna Intrator
- Geriatrics and Extended Care Data Analysis Center, Office of Geriatrics and Extended Care, US Department of Veterans Affairs, Washington, DC, United States; Canandaigua Veterans Affairs Medical Center, Canandaigua, NY, United States; Department of Public Health Sciences, University of Rochester, Rochester NY, United States
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, United States; Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, United States
| | - Ilse R Wiechers
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, MI, United States; Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA, United States; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Michele J Karel
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, MI, United States
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21
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Trenaman SC, Bowles SK, Kirkland SA, Andrew MK. Potentially Inappropriate Drug Duplication in a Cohort of Older Adults with Dementia. CURRENT THERAPEUTIC RESEARCH 2021; 95:100644. [PMID: 34589160 PMCID: PMC8458971 DOI: 10.1016/j.curtheres.2021.100644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 08/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Concurrent use of 2 nonsteroidal anti-inflammatory drugs, selective serotonin reuptake inhibitors, loop diuretics, angiotensin-converting enzyme inhibitors, or anticoagulants is considered potentially inappropriate by Screening Tool of Older Persons' Prescriptions and Screening Tool to Alert to Right Treatment criteria. OBJECTIVE The objective was to examine drug duplication in a cohort of older adults with dementia. METHODS Cohort entry for Nova Scotia Seniors' Pharmacare Program beneficiaries was the date an International Classification of Diseases ninth edition or 10th edition code for dementia was recorded in accessed databases between March 1, 2005, and March 31, 2015. Medication dispensation and sociodemographic data were captured from the Nova Scotia Seniors' Pharmacare Program database between April 1, 2010, and March 31, 2015. Duplication was considered when 2 drugs from the same class were dispensed such that the supply in the patient's possession could overlap for more than 30 days. We reported number of cases of duplication and duration of overlap. Sex differences in drug duplication were assessed with bivariate logistic regression. RESULTS In the cohort of 28,953 Nova Scotia Seniors' Pharmacare Program beneficiaries with dementia, we documented concurrent use in 101 (1.7%) nonsteroidal anti-inflammatory drugs users (mean duration = 75.6 days), 95 (1.0%) selective serotonin reuptake inhibitors users (mean duration = 146.6 days), 5 (0.07%) loop diuretic users (mean duration = 530.6 days), 183 (2.0%) angiotensin-converting enzyme inhibitor users (mean duration = 123.9 days), and 160 (3.5%) anticoagulant users (mean duration = 63.6 days). Nonsteroidal anti-inflammatory drug pairs were most commonly celecoxib with naproxen or diclofenac. Selective serotonin reuptake inhibitors duplication was most commonly sertraline with citalopram. No sex differences in risk for drug duplication were identified. CONCLUSIONS Drug duplication was identified in a cohort of older adults with dementia and is a feasible target for intervention. (Curr Ther Res Clin Exp. 2021; 82:XXX-XXX).
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Affiliation(s)
- Shanna C. Trenaman
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Susan K. Bowles
- Nova Scotia Health, Halifax, Nova Scotia, Canada
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Susan A. Kirkland
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Melissa K. Andrew
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Nova Scotia Health, Halifax, Nova Scotia, Canada
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22
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Borda MG, Castellanos-Perilla N, Tovar-Rios DA, Oesterhus R, Soennesyn H, Aarsland D. Polypharmacy is associated with functional decline in Alzheimer's disease and Lewy body dementia. Arch Gerontol Geriatr 2021; 96:104459. [PMID: 34225098 DOI: 10.1016/j.archger.2021.104459] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 05/28/2021] [Accepted: 06/09/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND In dementia, a number of factors may influence functional decline in addition to cognition. In this study, we aimed to study the potential association of the number of prescribed medications with functional decline trajectories over a five-year follow-up in people diagnosed with mild Alzheimer's disease (AD) or Lewy Body dementia (LBD). METHODS This is a longitudinal analysis of a Norwegian cohort study entitled "The Dementia Study of Western Norway". We included 196 patients newly diagnosed with AD (n=111) and LBD (n=85), followed annually for 5 years. We conducted linear mixed-effects models to analyse the association of the number of medications with functional decline measured by the Rapid Disability Rating Scale - 2. RESULTS The mean prescribed medications at baseline was 4.18∓2.60, for AD 3.92∓2.51 and LBD 4.52∓2.70. The number of medications increased during the follow-up; at year five the mean for AD was 7.28∓4.42 and for LBD 8.11∓5.16. Using more medications was associated with faster functional decline in AD (Est 0.04, SE 0.01, p-value 0.003) and LBD (Est 0.08, SE 0.03, p-value 0.008) after adjusting for age, sex, comorbidity, neuropsychiatric symptoms, and cognition. For each medication added during the follow-up, functional trajectories worsened by 1% for AD and 2% for LBD. The number of medications was not associated with cognitive decline. CONCLUSION We found that higher number of medications was related to a faster functional decline, both in AD and LBD. With disease progression, there was an increase in the number of medications. Prescription in dementia should be carefully assessed, possibly improving the functional prognosis.
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Affiliation(s)
- Miguel Germán Borda
- Centre for Age-Related Medicine (SESAM), Stavanger University Hospital, Stavanger, Norway; Semillero de Neurociencias y Envejecimiento, Ageing Institute, Medical School, Pontificia Universidad Javeriana. Bogotá, Colombia; Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.
| | - Nicolás Castellanos-Perilla
- Centre for Age-Related Medicine (SESAM), Stavanger University Hospital, Stavanger, Norway; Semillero de Neurociencias y Envejecimiento, Ageing Institute, Medical School, Pontificia Universidad Javeriana. Bogotá, Colombia
| | - Diego Alejandro Tovar-Rios
- Centre for Age-Related Medicine (SESAM), Stavanger University Hospital, Stavanger, Norway; Universidad Del Valle, Grupo de Investigación en Estadística Aplicada - INFERIR, Faculty of Engineering, Santiago De Cali, Valle Del Cauca, Colombia.; Universidad Del Valle, Prevención y Control de la Enfermedad Crónica - PRECEC, Faculty of Health, Santiago De Cali, Valle Del Cauca, Colombia
| | - Ragnhild Oesterhus
- Centre for Age-Related Medicine (SESAM), Stavanger University Hospital, Stavanger, Norway; The Hospital Pharmacy Enterprise of Western Norway, Bergen, Norway
| | - Hogne Soennesyn
- Centre for Age-Related Medicine (SESAM), Stavanger University Hospital, Stavanger, Norway
| | - Dag Aarsland
- Centre for Age-Related Medicine (SESAM), Stavanger University Hospital, Stavanger, Norway; Department of Old Age Psychiatry, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
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23
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Suzuki Y, Sakakibara M, Shiraishi N, Komiya H, Akishita M, Kuzuya M. Use of Anti-Dementia Drugs Reduces the Risk of Potentially Inappropriate Medications: A Secondary Analysis of a Nationwide Survey of Prescribing Pharmacies. Dement Geriatr Cogn Disord 2021; 49:526-532. [PMID: 33279893 PMCID: PMC7949214 DOI: 10.1159/000512043] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 09/30/2020] [Indexed: 11/19/2022] Open
Abstract
AIMS As the number of older people with dementia increases, safe pharmacotherapy in this population has attracted attention in recent years. The aims of this study were to clarify the prescribing patterns in older patients who were prescribed anti-dementia drugs and to investigate the association of potentially inappropriate medications (PIMs) with the use of anti-dementia drugs. METHODS Adults aged ≥65 years, who were prescribed anti-dementia drugs at 585 pharmacies across Japan (N = 7,953), were surveyed. The percentage of prescriptions of anti-dementia drugs and the effect of those prescriptions on PIMs were investigated. RESULTS Prescriptions of anti-dementia drugs were found in 4.4% of the entire study population. A multiple logistic regression analysis revealed that the use of anti-dementia drugs reduced the risk of prescribing psychotropic drugs, which represented PIMs, and that a combination of anti-dementia drugs (e.g., cholineesterase inhibitor with memantine) may reduce the risk of prescribing PIMs compared with monotherapy. CONCLUSION The use of anti-dementia drugs was associated with fewer prescriptions of drugs considered as PIMs.
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Affiliation(s)
- Yusuke Suzuki
- Center for Community Liaison and Patient Consultations, Nagoya University Hospital, Nagoya, Japan,
| | | | - Nariaki Shiraishi
- Department of Rehabilitation, Faculty of Health Sciences, Nihon Fukushi University, Nihon, Japan
| | - Hitoshi Komiya
- Center for Community Liaison and Patient Consultations, Nagoya University Hospital, Nagoya, Japan
| | - Masahiro Akishita
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masafumi Kuzuya
- Department of Community Healthcare and Geriatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
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24
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Growdon ME, Gan S, Yaffe K, Steinman MA. Polypharmacy among older adults with dementia compared with those without dementia in the United States. J Am Geriatr Soc 2021; 69:2464-2475. [PMID: 34101822 DOI: 10.1111/jgs.17291] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/27/2021] [Accepted: 05/01/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES In older persons with dementia (PWD), extensive medication use is often unnecessary, discordant with goals of care, and possibly harmful. The objective of this study was to determine the prevalence and medication constituents of polypharmacy among older PWD attending outpatient visits in the United States. DESIGN Cross-sectional analysis. SETTING AND PARTICIPANTS PWD and persons without dementia (PWOD) aged ≥65 years attending outpatient visits recorded in the nationally representative National Ambulatory Medical Care Survey (NAMCS), 2014-2016. MEASUREMENTS PWD were identified as those with a diagnosis of dementia on the NAMCS encounter form and/or those receiving an anti-dementia medication. Visits with PWD and PWOD were compared in terms of sociodemographic, practice/physician factors, comorbidities, and prescribing outcomes. Regression analyses examined the effect of dementia diagnosis on contributions by clinically relevant medication categories to polypharmacy (defined as being prescribed ≥5 prescription and/or nonprescription medications). RESULTS The unweighted sample involved 918 visits for PWD and 26,543 visits for PWOD, representing 29.0 and 780 million outpatient visits. PWD had a median age of 81 and on average had 2.8 comorbidities other than dementia; 63% were female. The median number of medications in PWD was eight compared with three in PWOD (p < 0.001). After adjustment, PWD had significantly higher odds of being prescribed ≥5 medications (AOR 3.0; 95% CI: 2.1-4.3) or ≥10 medications (AOR 2.8; 95% CI: 2.0-4.2) compared with PWOD. The largest sources of medications among PWD were cardiovascular and central nervous system medications; usage from other categories was generally elevated in PWD compared with PWOD. PWD had higher odds of receiving at least one highly sedating or anticholinergic medication (AOR 2.5; 95% CI: 1.6-3.9). CONCLUSION In a representative sample of outpatient visits, polypharmacy was extremely common among PWD, driven by a wide array of medication categories. Addressing polypharmacy in PWD will require cross-cutting and multidisciplinary approaches.
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Affiliation(s)
- Matthew E Growdon
- Division of Geriatrics, University of California, San Francisco, California, USA.,San Francisco VA Medical Center, San Francisco, California, USA
| | - Siqi Gan
- Division of Geriatrics, University of California, San Francisco, California, USA.,San Francisco VA Medical Center, San Francisco, California, USA
| | - Kristine Yaffe
- San Francisco VA Medical Center, San Francisco, California, USA.,Departments of Neurology, Psychiatry, and Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco, California, USA.,San Francisco VA Medical Center, San Francisco, California, USA
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25
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Barry HE, McGrattan M, Ryan C, Passmore AP, Robinson AL, Molloy GJ, Darcy CM, Buchanan H, Hughes CM. 'I just take them because I know the people that give them to me': A theory-informed interview study of community-dwelling people with dementia and carers' perspectives of medicines management. Int J Geriatr Psychiatry 2021; 36:883-891. [PMID: 33368704 DOI: 10.1002/gps.5488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/22/2020] [Accepted: 12/19/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Identify facilitators and barriers to successful medicines management for people with dementia (PwD) in primary care from the perspectives of community-dwelling PwD and carers. METHODS Semi-structured interviews conducted with PwD and carers in Northern Ireland. The 14-domain Theoretical Domains Framework guided data collection and analysis. Interviews explored participants' experiences and perceptions of medicines management. PwD also completed the Beliefs about Medicines Questionnaire indicating their level of agreement with statements about medicines. Qualitative data were analysed using the framework method and content analysis. Quantitative data were analysed descriptively. RESULTS Eighteen PwD and 15 carers were interviewed. PwD believed they were competent with medicines management ('beliefs about capabilities'). Most PwD reported having strategies to prompt them to take their medicines ('memory, attention and decision processes'). Carers played an important role in supporting PwD with medicines management ('social influences') and monitoring adherence ('behavioural regulation') and anticipated having to take on a greater role as patients' cognitive impairment worsened ('beliefs about consequences'). Participants highlighted assistance provided by community pharmacies with medicines acquisition and delivery ('environmental context and resources') and placed great trust in primary healthcare professionals ('social influences'). PwD had positive attitudes towards medication and believed strongly in the necessity of their medicines. CONCLUSIONS This is the first study to use a theoretical approach to explore medicines management for community-dwelling PwD. The findings provide new insights into the critical role of carers in facilitating optimal medicines management and will inform future intervention development, in which carers' needs assessment and involvement will be key.
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Affiliation(s)
| | | | - Cristín Ryan
- The School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - A Peter Passmore
- Centre for Public Health, Queen's University Belfast, Belfast, UK.,Belfast Health & Social Care Trust, Belfast, UK
| | - A Louise Robinson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Gerard J Molloy
- School of Psychology, National University of Ireland, Galway, Ireland
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26
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Healthcare Utilization in Different Stages among Patients with Dementia: A Nationwide Population-Based Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115705. [PMID: 34073398 PMCID: PMC8199003 DOI: 10.3390/ijerph18115705] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/17/2021] [Accepted: 05/24/2021] [Indexed: 11/16/2022]
Abstract
To evaluate the trend of healthcare utilization among patients with dementia (PwD) in different post-diagnosis periods, Taiwan's nationwide population database was used in this study. PwD were identified on the basis of dementia diagnoses during 2002-2011. We further subdivided the cases into 10 groups from the index year to the 10th year after diagnosis. The frequency of emergency department visits and hospitalizations, the length of stay, outpatient and department visits, and the number of medications used were retrieved. The Joinpoint regression approach was used to estimate the annual percent change (APC) of healthcare utilization. The overall trend of healthcare utilization increased with the progression of dementia, with a significant APC during the first to second year after diagnosis (p < 0.01), except that the frequency of outpatient visits showed a decreasing trend with a significant APC from the first to fifth year. All sex- and age-stratified analyses revealed that male gender and old age contributed to greater use of healthcare services but did not change the overall trend. This study provides a better understanding of medical resource utilization across the full spectrum of dementia, which can allow policymakers, physicians, and caregivers to devise better care plans for PwD.
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27
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Ferreira TR, Lopes LC, Motter FR, de Cássia Bergamaschi C. Potentially inappropriate prescriptions to Brazilian older people with Alzheimer disease: A cross-sectional study. Medicine (Baltimore) 2021; 100:e25015. [PMID: 33761656 PMCID: PMC9282042 DOI: 10.1097/md.0000000000025015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 02/12/2021] [Indexed: 01/05/2023] Open
Abstract
Older adults are the leading users of medications, where this can be associated with a high number of potentially inappropriate medications (PIMs) and of potentially inappropriate prescribing (PIP) and consequent harm to health. No Brazilian study evaluating potentially inappropriate prescribing in older patients with Alzheimer's disease (AD) was found. This study determined and analyzed the prevalence of PIP and PIM prescribed for older people with AD.A cross-sectional study was carried out at the Specialty Drugs Pharmacy in the city of Sorocaba, São Paulo State, Brazil. The MEDEX system provided the register in older people with AD and data were collected during interviews with patients and/or caregivers between June and September 2017. The PIMs were identified according to the 2019 Beers Criteria. The association between PIMs and independent variables was analyzed by Poisson regression.This study included 234 older patients with AD. The prevalence of PIP prescribed was 66.7% (n = 156). Of the 1073 medications prescribed, 30.5% (n = 327) were inappropriate with most affecting the central nervous system or cardiovascular, particularly quetiapine (12.8%) and acetylsalicylic acid (11.6%), respectively. Around 45.2% of the PIMs should be avoided in older people, especially sertraline (14.2%) and clonazepam (7.4%). After adjusted analysis, the PIMs were associated with the diagnosis of depression (P = 0.010) and the number of comorbidities (P = 0.005).There was a high number of PIMs among older people, a substantial number of which should have been avoided in this population. Health care professionals can apply these findings to improve safety in the use of medications for treating patients with AD.
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Affiliation(s)
- Tânia Regina Ferreira
- Postgraduate Program in Pharmaceutical Sciences, University of Sorocaba, Sorocaba, State of São Paulo, Brazil
| | - Luciane Cruz Lopes
- Postgraduate Program in Pharmaceutical Sciences, University of Sorocaba, Sorocaba, State of São Paulo, Brazil
| | - Fabiane Raquel Motter
- Postgraduate Program in Pharmaceutical Sciences, University of Sorocaba, Sorocaba, State of São Paulo, Brazil
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28
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Kristensen RU, Jensen-Dahm C, Gasse C, Waldemar G. Declining Use of Potentially Inappropriate Medication in People with Dementia from 2000 to 2015: A Repeated Cross-Sectional Nationwide Register-Based Study. J Alzheimers Dis 2021; 79:1459-1470. [PMID: 33459711 PMCID: PMC7990423 DOI: 10.3233/jad-200627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Studies have shown declining use of potentially inappropriate medication (PIM), medication where risks associated with use outweigh potential benefits in older people. However, the trend in people with dementia remains unknown. Objective: To test the hypothesis that the use of PIM has decreased in people with dementia in line with the declining use in the general older population. Methods: Repeated cross-sectional register-based study of the entire Danish population aged ≥65 years (2000: N = 802,106; 2015: N = 1,056,476). PIM was identified using the Danish “Red-yellow-green list”. Changes in the use of PIM were examined by calculating the annual prevalence of filling prescriptions for at least one PIM in older people with and without dementia. Characteristics of the study population were examined annually including comorbidity. Results: From 2000 to 2015, the prevalence of PIM use decreased from 54.7%to 43.5%in people with dementia and from 39.5%to 28.8%in people without dementia; the decrease was significant across all age groups and remained so in a sensitivity analysis where antipsychotics were removed. During the same period, comorbidity scores increased in people with and without dementia. Conclusion: The declining use of PIM in people with dementia from 2000 to 2015 parallels the trend in the general older population. The use of PIM decreased despite increasing levels of comorbidity and was not solely attributable to the decreasing use of antipsychotics in people with dementia. However, PIM use remained more widespread in people with dementia who may be more vulnerable to the risks associated with PIM.
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Affiliation(s)
- Rachel Underlien Kristensen
- Danish Dementia Research Centre (DDRC), Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen Ø, Denmark
| | - Christina Jensen-Dahm
- Danish Dementia Research Centre (DDRC), Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen Ø, Denmark
| | - Christiane Gasse
- Department of Affective Disorders, Aarhus University Hospital, Psychiatry, Aarhus N, Denmark.,Psychosis Research Unit, Aarhus University Hospital, Psychiatry, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus C, Denmark
| | - Gunhild Waldemar
- Danish Dementia Research Centre (DDRC), Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen Ø, Denmark
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29
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Harasani K, Xhafaj D, Begolli A, Olvera-Porcel MC. Prevalence of potentially inappropriate prescriptions in primary care and correlates with mild cognitive impairment. Pharm Pract (Granada) 2020; 18:2017. [PMID: 32922574 PMCID: PMC7470240 DOI: 10.18549/pharmpract.2020.3.2017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 08/16/2020] [Indexed: 11/30/2022] Open
Abstract
Background: Potentially inappropriate prescribing is clearly associated with adverse
health consequences among older people. Nevertheless, scarce evidence exists
regarding the prevalence of potentially inappropriate prescriptions (PIP) in
Albania, a Western Balkans country. Objective: The aim of this study was to assess the prevalence of PIP among older
Albanian patients in primary care and to determine the associated
sociodemographic and medical factors, including the presence of mild
cognitive impairment (MCI). Methods: Cross-sectional study in two primary healthcare centers located in two
different cities of Albania, a middle-income country in the Western Balkans.
The Montreal Cognitive Assessment (MoCA) tool was applied to evaluate MCI.
PIPs were assessed by two trained pharmacists using the Beers criteria 2019
update. Multivariate logistic regression analysis was conducted for possible
risk factors predicting PIP in the study population. Results: At least one PIP was identified among 40.23 % of the participants (174
older patients) and 10.35 % had more than one PIP. MCI was detected
among 79.31 % of the patients. The most commonly represented drug
groups in PIP were diuretics (24.71 %), benzodiazepines in the
presence of MCI and antidepressants (both 8.62 %). The lack of
electrolytes monitoring was the most common reason for PIP. According to the
multivariate analysis, the only statistically significant association
observed was between PIP and number of drugs prescribed [three to four drugs
(OR 3.34; 95% CI 1.65:6.76), five or more than five drugs (OR 4.08;
95% CI 1.42:11.69)]. Conclusions: About four out of 10 older Albanian patients experience PIP in primary care.
Further studies are needed for a comprehensive estimation of the prevalence
and factors associated with PIP, particularly among elderly with mild
cognitive impairment.
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Affiliation(s)
- Klejda Harasani
- PhD. Department of Pharmacy, Faculty of Medicine, University of Medicine of Tirana. Tirana (Albania).
| | - Delina Xhafaj
- PhD. Department of Pharmacy, Faculty of Medicine, University of Medicine of Tirana. Tirana (Albania).
| | - Anxhela Begolli
- MSc. Department of Pharmacy, Faculty of Medicine, University of Medicine of Tirana. Tirana (Albania).
| | - Maria C Olvera-Porcel
- PhD. Public Foundation for Biomedical Research of Oriental Andalusia. Granada (Spain).
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